Q&A with Physio Matt Todman

Catch up with the highlights from our recent webchat with Six Physio physio Matt Todman.

Matt qualified as a physio 20 years ago and has spent the past decade at the forefront of sports medicine. He works as a consultant in private practice dealing with everyone from elite level runners to beginners.

Q1. I’m grateful for the opportunity to raise this question with you as “Dr Google” has thrown up a myriad of possible issues with few obvious solutions… I have a ‘clicking hip’. My running biomechanics are poor but at 30 years old (I’ve been a hobby runner / triathlete for only three years) and relatively heavy set, it would seem there is little chance of drastically changing these. The most obvious defect is the rotation in my right foot is greater than my left which results in it turning out (say 35-45 degrees from straight forward) whilst running, to a greater degree in the Marathons I run biannually. The clicking hip is on the right hand side and is definitely not the top of my IT band. Days, weeks and months will often pass without issue and indeed I’ve covered a few 26.2 milers without provoking the problem but when it does present itself, I can feel a physical “clunk” (nothing audible) as the muscle / tendon / ligament passes over the hip area. If it presents itself during a long run, it will often serve as a catalyst for problems in other elements of my right leg, notably knee and quad. I regularly visit a sports masseuse and she recently suggested “the ligament(s) might not be sitting correctly” and that we should try some manipulation of the area. I am keen to hear what you think and what you suggest my next course of action is in trying to remedy the issue. Thanks in advance. – Robbie W

A1. Hips can make a myriad of different noise from clicks, clunks and deep seated thunks.

The foot rolling out is the clue. Our role in life (well, apart from a few other major ones!) is to get our knee caps facing forward. You’ve got an internally rotated femur – your thigh rolls in, and so does your kneecap. To get this pointing forward you point your foot out, which compensates for your rolled in thigh.

Your thigh rolls in for a major and a not so major reason. The former is poor gluteal control and the latter is a boney issue, which can’t be altered.

The clunk is the rotation of your hip in your socket and the deep muscles at the front rubbing across it. I’m not sure I’d worry about stretching the hip, which will make it feel (temporarily) looser but instead really work on improving your hip and pelvic control and not necessarily strength.

Q2. Is there such a thing as a phantom injury?

I have had 3 big races where I have been in agony the week before (knee, foot, hip) - with no history of trauma - that's left me limping, fretting and visiting physios, only to find absolutely no symptoms on race day at all, before, during or after the race.

Can pain be in the head sometimes? – Britrisky

A2. Yup, absolutely. It’s far more common than imagined. Just recognise that it can happen, understand it and crack on. If it doesn’t get better within a few days – seek advice

Q3. I am currently struggling with a strained priformis causing sciatica. I am under treatment with a chiro but this does not seem to address the cause.

What would you suggest as a long-term fix as this seems to haunt me on and off.

Also, is it detrimental to think about low intensity training while in pain or is complete rest best? – Iron Muffin

A3. Absolutely agree with you. Piriformis strain, syndrome or tightness is a description of symptoms and very, very rarely a cause. There needs to be a really distinct clarification between a tight muscle and stiff muscle – but they’ll feel the same.

A tight muscle generally implies that the equal and opposite muscle is not be used and is (possibly) posturally controlled. This can be stretched to feel better, but until the opposite muscle is rehabbed then the symptoms will reoccur.

A stiff muscle is due to an increase in muscle tone, which is most likely to be a protective mechanism, and shouldn’t be stretched. Ever.

I think your piriformis is stiff to protect your sciatic nerve, not causing it. Why is it stiff is the question. The most common cause is a really stiff thoracic spine making your low lumbar spine relatively unstable (to the thoracic spine). The unstable lumbar spine causes your sciatic nerve to become irritated and your muscles (not just piriformis) contract to protect it and attempt to stabilise your lumbar spine. It fails woefully and just increases lumbar spine shear and joint compression.

Q4. Are there any stretches you can recommend for a triathlete who ends up with massive knots in the top of her shoulders about half way along each collar bone? They seem to be an issue whatever phase I'm doing. – AliBear30

A4. Any stretching around this area will make you feel better, but it’ll never get you better. The 2 are very different things.

Here’s why:

It’s most likely because you poke your chin out when swimming, biking or running. And you do this because you’ve got a super tight thoracic spine, which is great at bending forward, but can’t reverse and bend backward. You’ll cheat spectacularly by either bending your back backwards or poking your chin out to see where you’re going.

The muscle tightness is a product of what you’re doing to your neck and the opposite muscles (lower traps, serratus anterior) not doing very much.

Get more movement in your thoracic spine and improve the control of the muscles that look after your neck. This RWIC stretch still rocks http://www.runnersworld.co.uk/health/video-stretch-on-holiday/9575.html

Q5. I've recently upped my cross training, including boot camps, gym classes and know I haven't taken enough rest time, I stupidly tried to throw a 1/2 marathon run in the middle of that ( plus the usual aerobix, body attack ...all high impact ) I started to feel tightening up the back of my left leg that pinched into my bum at mile 9 but as I was out doors I was committed to returning to my car , I walked the last mile. The following day I could barely straighten the leg so I rested for three days and attempted a 10 k this morning managing half of that outdoors n then I came back n stretched n managed a more comfortable 2 mile on the treadmill. I visited the local uni for advice from their osteopath and they felt that my left side was slightly out of alignment. I had massage treatment and see them again in two weeks. They said I would be ok to try to continue exercising from tomorrow but that I should spend more time to warm up

Sorry, I was trying to have your opinion or to grab some extra advice re, stretches or treatment. My whole leg goes tight from the arch of the foot, up the calf and up the leg into my hip and bum. Thank you for your time hope I explained well enough. – Cheryl Griffiths

A5. I don’t think this sounds like a muscle….as it crosses too many joints and your symptoms follow your sciatic nerve rather a little too well to ignore it.

Stretching nerve tissue, whilst it may feel nice will make it worse later. The nerve becomes irritated because you loose control of your lumbar spine either due to excessive activity or not moving well enough elsewhere.

Work on control, balance and stability of your entire lower limb, from the pelvis/hip down and the foot up. Try to work out what does move enough and what – and get it to move (most commonly your thoracic spine) . Generally bits that don’t move very well, you won’t feel – as they don’t move. Things that feel stiff (especially spinally) aren’t really but you feel muscle stiffness protecting mobile joints…..

Q6. I am fairly new to long ish bike routes and at the start of the year acquired a defy 3 composite. My first road bike with drop handle bars.

When i go out for a longer ride - 40+ miles / 2 hours ish my left hand especially goes numb / tingly. It’s always the little finger and sometimes the next one in as well.

The bike is set up for me, via the shop - but they did it with me there - checking sizes and fits etc, but am I thinking this is a bike fit issue?

After a couple of days it goes away again.

Any advice would be great. - Budjude

A6. Sounds like your Ulnar nerve is being compromised due to prolonged posture of (surprise surprise) a stiff thoracic spine and poking chin posture – see all the other posts.

The most common bike fit issue is the distance from your saddle to handle bars – either being too far and putting lots of pressure down through your wrists or too near increasing the slouch position.

Should be pretty easy to rectify. Make sure you’re doing lots of scapular stability and rotator cuff control work off bike.

Q7. I've always been disappointed with physio advice about issues I've had (over the last 30 years), except I did find a good guy last time around who actually understood the level and depth of sport i was doing.

So here's my question, how 'equal' are physios when it comes to knowledge of treating people who regularly train and race?

And how do you find a good physio without spending buckets finding the wrong ones first? – kittenkat

A7. We’re not (thankfully!) equal – some are great, some are terrible and lots are pretty ineffective – and that’s hard for me as a physio to accept.

It’s not all about letters-after-names, years qualified or where they’ve worked. Some elite level physios are terrible - dining out on clubs reputations, whilst some independent practitioners – be them SM,osteos or chiros are bloody great.

Reputation is everything. Participation can give a little more but more importantly is the physio asking and totally understanding what you do, how and why.

We don’t have magic fingers and definitely no magic machines, but we must have the ability to make you move better so you can repair your self. The rehab component teaches you to move better, for longer. Unless it’s a traumatic injury symptom relief is not the same as dealing with the cause.

Ask, ask and re-ask. Someone somewhere will know who the don is. You do need to kiss a lot of frogs…

Q8. When I ran a marathon the last 2/3 miles were agony - not because of my legs but my lower back! Every step caused me pain in my back, and when I finished I realised it was grossly swollen - I had totally lost the curvature in my back. It was tender and I couldn't have anything touch it. It resolved itself after about 24 hours.

I never had anything like it in training, although only ran about 21 miles in training.

I do intermittently get very mild lower back pain - I think due to poor posture and occasional poor liftinag at work. Never had any swelling since but I'm worried it will be a problem when I do an ironman.

I thought it might be poor posture/weak core. I now work on my core twice a week at the gym. - MedicGirl

A8. Sounds very fair – grossly swollen, rather than just protected by muscle spasm, sounds like an acute bone/joint reaction and shouldn’t be taken lightly. I think your approach sounds on the money. Get more stable then stronger, then maybe think about getting your running style looked.